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Designa Underground Storage Tank (US Operator Monthly Visual Inspection Checklist Name: SAN JOAQUIN GENERAL HOSPITAL Date: / Address: 500 WEST HOSPITAL ROAD FRENCH CAMP Zip Code: CA 95231 Led UST erator Conducting the Inspection: JESSE BERUMEN onal Council Certification 8014628 -UC Ex iration Date: 05/24/2018 e Phone: ( 209 ) 367-4800 T3AIarm 0 MONITORING PANEL--/—AL--ARM HISTORY onitorin s stem is owered on and in ro er operating mode. onitorin s stem is not currentlyshowin analarms or warnings. history report/log for the previous month is available, and has been reviewedby the si nated UST O erat6r. (Attach a co y o the alarm history re ort/lo to thisform i ach alarm for the revious month has been res onded to aro riatel . nsors located in tank -to containment sum s have not alarmed in the ast month. List all tank -top sumps where alarms occurred in the past month: N=No. NA= Ml Note: Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded properly addressed, the cause of the alarm. Attach documentation ver fying appropriate service to this report. Is= ins ection is required, record results in item 6, below. 6 --. — — e Vi L'%l 11V1\ Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located prop( Note: Visual ins ction of sums is on re wired in su1where arm hasoccurred in the ast month or which there is no sY to 17 Sum Location: T INE SUMP XSum Location: Sum Location: PIPING SUMP XSum Sum Location: Location:' :. Sum Location: r'' 7 Spill containment structures are free of water, debris, and hazardous substance. Y N NA Tank 1 — Contents: FILL BUCKET X Tank 3 — Contents: _ # 8 Tank 2 —Contents: X Tank 4 — Contents: j Under -dispenser containment areas are free of water, debris, and hazardous substance. lq Y N NA Dis enser 1/ 2 X Dis enser 9 / 10 _Dispenser 3 / 4 X Dispenser 11 / 12 Dispenser 5 / 6 X Dis enser 13114 Disenser 7 / 8 X Dispenser 15 / 16 MENEM PAPERWORK INSPECTION 7YN j10 Monitorin s stem certification has been com leted within ast 12 months. Secon containment tests have been com leted within the re aired timeframe. Sill containment structure ucket testin was com leted within the ast ear.08/2t)/..' Tank ti fitnetetwaithin re wired timeframe. Line tightness testing was completed within required timeframe. SEE COMMENTS X 08/27/2015 14 Other required test in maintenance was com leted within re uired timeframe. Test: T `''� : Cbp�jmeQ3 4/2018 X 03/24/2015 Test/Maintenance: Test/Maintenance: FACILITY EMPLOYEETRAINING Y N NA 15 All facili employees have received the required on-the-'ob trainingwithin the past year. X 16 All facili em to ees hired within the ast 30 days have received the re uired on-the-'ob trainin X Note: Any answer of "N" should be explained in the comment section on the following page, and will require follow-up action. Page 1 of 2 November 2004 to 17 PAPERWORK INSPECTION 7YN j10 Monitorin s stem certification has been com leted within ast 12 months. Secon containment tests have been com leted within the re aired timeframe. Sill containment structure ucket testin was com leted within the ast ear.08/2t)/..' Tank ti fitnetetwaithin re wired timeframe. Line tightness testing was completed within required timeframe. SEE COMMENTS X 08/27/2015 14 Other required test in maintenance was com leted within re uired timeframe. Test: T `''� : Cbp�jmeQ3 4/2018 X 03/24/2015 Test/Maintenance: Test/Maintenance: FACILITY EMPLOYEETRAINING Y N NA 15 All facili employees have received the required on-the-'ob trainingwithin the past year. X 16 All facili em to ees hired within the ast 30 days have received the re uired on-the-'ob trainin X Note: Any answer of "N" should be explained in the comment section on the following page, and will require follow-up action. Page 1 of 2 November 2004